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Communication is the key to compliance

Briefings on Infection Control, May 1, 2009

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It’s difficult enough to establish effective means of communication between the IC team and frontline staff members in the same hospital, let alone other facilities.

But regardless of how difficult it may be, that’s what The Joint Commission (formerly JCAHO) is asking of facilities in standard IC.02.01.01, particularly in elements of performance (EP) 9–11. These EPs require facilities to communicate IC information among their own staff members as well as to outside authorities such as federal, state, and local regulators and other healthcare facilities during patient transfers.

Looking at state requirements

Each state is going to have a different set of requirements concerning reporting, but rest assured that a surveyor will know what standards your state has in place and whether you are following them, says Patty Burns, RN, CIC, comanager of the IC program at St. Elizabeth Medical Center in Edgewood, KY.

“I think they vary a lot,” Burns says of the state requirements. “So I think the very first thing The Joint Commission [surveyors are] going to do is prep themselves on what the regulations are in your state to make sure you are doing that.”

Pennsylvania state laws mandate hospitals report healthcare-associated infections (HAI) through Act 52. As a result, Pennsylvania hospitals report infections electronically through the National Healthcare Safety Network, with authority granted to the Pennsylvania Health Care Cost Containment Council and the Pennsylvania Patient Safety Authority to access that information.

Although it was a rocky start at first, the reporting requirement actually made things a lot easier in the long run, says Deborah Frye, MT (ASCP), MBA, CIC, an infection preventionist at Lehigh Valley Hospital and Health Network in Allentown, PA.

This year, Lehigh Valley is up for its Joint Commission accreditation survey, and Act 52 has made that part of the preparation process easier because EP 9 is already met. “It sort of softens the burden of the Joint Commission requirements because you have all that data and you are able to identify areas of improvement,” says Frye.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Infection Control.

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